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Based on interview and record review, it was determined the hospital failed to ensure physicians orders were obtained for a physical restraint for 1 of 3 patient's reviewed [Patient #2].

Findings Included:

Patient #2's discharge summary dated 07/28/10 reflected, medical diagnosis was "bipolar with mixed episode with psychosis and borderline traits..."

The physician progress note dated 06/16/10 timed 0920 late entry reflected, "patient came back from hearing yesterday to get her things from the unit. She remained very labile, intrusive, argumentative, paranoid and disorganized. I was on the unit at the time when she began screaming and yelling at a peer[unprovoked] then threatened her. Staff had to intervene. I asked staff to remove patient from the unit and take her to the front lobby. Before they were able to do this she was screaming at staff threatening them and them balled her fist and was about to strike the nurse, patient was physically stopped by the MHT. Patient attempted to hit so was placed in hold...started a new OPC at that time..."

On 08/4/10 at 11:36 AM RN #2 was interviewed. RN #2 was asked to review her nursing note dated 06/15/10 at 1523. RN#2 stated Patient #2 was physically restrained due to aggressive behavior even after multiple attempts at redirection. RN #2 was asked by the surveyor if restraint orders were obtained. RN #2 reveiwed the medical record and stated she must of forgotten to get the physician to write the order.

The policy entitled, "Use of restraint/seclusion" with a review date of 10/09 reflected, "Physical restraint or seculsion must be ordered by a physician and continued only as long as the patient is at risk for harming self or others...when placed in seculsion or physical restraint..."

Based on interview and record review, it was determined the hospital failed to ensure 1 of 3 patients reviewed [Patient #2's] nursing care needs was evaluated by the Registered Nurse for an elevated temperature of 101.2.

Findings Included:

Patient #2's discharge summary dated 07/28/10 reflected "medical diagnosis were bipolar with mixed episode with psychosis and borderline traits..."

The computer generated progress note dated 06/14/10 timed at 07:30 reflected, "Temperature 101.2" no further documentation was found indicating Patient #2's temperature was addressed by the nurse until 06/15/10 at 2100 when Patient #2's temperature had increased to 104.6.

The physician orders dated 06/14/10 reflected no orders which addressed Patient #2's initial temperature of 101.2.

On 08/4/10 at 11:00 AM Personnel #4 was interviewed. Personnel #4 was asked by the surveyor to review medical record entry for 06/14/10 timed at 07:30. Personnel #4 stated she always shows the nurse the tech worksheet with the vital signs on it.

On 08/4/10 at11:36 AM Registered Nurse #2 was interviewed. RN #2 was asked to review Patient #2's medical record for 06/14/10. RN #2 stated she did not remember being notified by the tech that Patient #2 had a temperature. RN #2 stated she did not address Patient #2's elevated temperature.

The hospital policy entitled, "Vital signs and Weights" with a review date of 09/08 reflected, "objective to collect and record on the patient's electronic medical record baseline medical data as a part of the patient's treatment plan...vital signs will be taken if a patient's medical status changes...abnormal findings are to be reported to the RN or MD [Medical Doctor]...temperature greater than 100.5..."

Based on interview and record review, it was determined the hospital failed to ensure physicians orders were obtained for a physical restraint for 1 of 3 patient's reviewed [Patient #2].

Findings Included:

Patient #2's discharge summary dated 07/28/10 reflected, medical diagnosis was "bipolar with mixed episode with psychosis and borderline traits..."

The physician progress note dated 06/16/10 timed 0920 late entry reflected, "patient came back from hearing yesterday to get her things from the unit. She remained very labile, intrusive, argumentative, paranoid and disorganized. I was on the unit at the time when she began screaming and yelling at a peer[unprovoked] then threatened her. Staff had to intervene. I asked staff to remove patient from the unit and take her to the front lobby. Before they were able to do this she was screaming at staff threatening them and them balled her fist and was about to strike the nurse, patient was physically stopped by the MHT. Patient attempted to hit so was placed in hold...started a new OPC at that time..."

On 08/4/10 at 11:36 AM RN #2 was interviewed. RN #2 was asked to review her nursing note dated 06/15/10 at 1523. RN#2 stated Patient #2 was physically restrained due to aggressive behavior even after multiple attempts at redirection. RN #2 was asked by the surveyor if restraint orders were obtained. RN #2 reveiwed the medical record and stated she must of forgotten to get the physician to write the order.

The policy entitled, "Use of restraint/seclusion" with a review date of 10/09 reflected, "Physical restraint or seculsion must be ordered by a physician and continued only as long as the patient is at risk for harming self or others...when placed in seculsion or physical restraint..."

Based on interview and record review, it was determined the hospital failed to ensure 1 of 3 patients reviewed [Patient #2's] nursing care needs was evaluated by the Registered Nurse for an elevated temperature of 101.2.

Findings Included:

Patient #2's discharge summary dated 07/28/10 reflected "medical diagnosis were bipolar with mixed episode with psychosis and borderline traits..."

The computer generated progress note dated 06/14/10 timed at 07:30 reflected, "Temperature 101.2" no further documentation was found indicating Patient #2's temperature was addressed by the nurse until 06/15/10 at 2100 when Patient #2's temperature had increased to 104.6.

The physician orders dated 06/14/10 reflected no orders which addressed Patient #2's initial temperature of 101.2.

On 08/4/10 at 11:00 AM Personnel #4 was interviewed. Personnel #4 was asked by the surveyor to review medical record entry for 06/14/10 timed at 07:30. Personnel #4 stated she always shows the nurse the tech worksheet with the vital signs on it.

On 08/4/10 at11:36 AM Registered Nurse #2 was interviewed. RN #2 was asked to review Patient #2's medical record for 06/14/10. RN #2 stated she did not remember being notified by the tech that Patient #2 had a temperature. RN #2 stated she did not address Patient #2's elevated temperature.

The hospital policy entitled, "Vital signs and Weights" with a review date of 09/08 reflected, "objective to collect and record on the patient's electronic medical record baseline medical data as a part of the patient's treatment plan...vital signs will be taken if a patient's medical status changes...abnormal findings are to be reported to the RN or MD [Medical Doctor]...temperature greater than 100.5..."